Andres Falabella

One hundred five penetrating cardiac injuries : a 2-year prospective evaluation

OBJECTIVES To analyze the parameters measured in the field, during transport, and upon arrival of the physiologic condition of patients sustaining penetrating cardiac injuries, along with the Cardiovascular Respiratory Score (CVRS) component of the Trauma Score, the mechanism and anatomical site of injury, operative characteristics, and cardiac rhythm as predictors of outcome. We also set out to identify a set of patient characteristics that best predict mortality outcome and to correlate cardiac injury grade as determined by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) with mortality. METHODS This report was a prospective study at American College of Surgeons Level I urban trauma center. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury. The main outcome measures used were those parameters measuring physiologic condition of patients, CVRS, mechanism and anatomical site of injury, mortality, and grade of injury. RESULTS A total of 105 patients sustained penetrating cardiac injuries: 68 injuries (65%) were gunshot wounds and 37 injuries (35%) were stab wounds. The mean Injury Severity Score was 36. Of the 105 wounds, 23 wounds (22%) involved multiple-chamber injuries. The overall survival was 35 of 105 patients (33%): survival of gunshot wound victims was 11 of 68 patients (16%); survival of stab wound victims was 24 of 37 patients (65%). Emergency department thoracotomy was performed in 71 of the 105 patients (68%) with 10 survivors (14%). CVRS: 94% mortality (50 of 53) when CVRS = 0, 89% mortality (57 of 64) when CVRS = 0 to 3, and 31% mortality (12 of 39) when CVRS 4 to 11 (p < 0.001). The presence of sinus rhythm when pericardium was opened predicted survival (p < 0.001). Anatomical site of injury (injured chamber) and the presence of tamponade did not predict survival. Stepwise logistic regression analysis identified gunshot wound, exsanguination, and restoration of blood pressure as most predictive variables of mortality. AAST-OIS injury grade and mortality: grade I, 0 of 1 (0%); grade II, 1 of 2 (50%); grade III, 2 of 3 (66%); grade IV, 28 of 50 (56%); grade V, 29 of 38 (76%); grade VI, 10 of 11 (91%). Overall incidence: grades IV-VI, 99 of 105 (94%). CONCLUSIONS Parameters measuring physiologic condition, CVRS, and mechanism of injury are significant predictors of outcome in penetrating cardiac injuries. AAST-OIS injury grades I-III are rare in penetrating cardiac trauma. AAST-OIS Injury grades IV-VI are common in penetrating cardiac trauma and accurately predict outcome.

Angiographic Embolization for Intraperitoneal and Retroperitoneal Injuries

Abstract. Angiographic embolization (AE) has been used extensively for bleeding control after injuries to the face and neck. Its role in abdominal trauma requires further exploration. We reviewed the medical records of 137 consecutive patients who underwent angiography with the intent to embolize bleeding sites within the abdomen. Of them, 97 (71%) had blunt and 40 (29%) had penetrating trauma. AE was performed for hemorrhage associated with pelvic fractures (97 patients), liver lacerations (n= 26), renal lacerations (n= 12), splenic lacerations (n= 5), other injuries (n= 9), and multiple injuries (n= 12). On angiography, 102 patients were found to have bleeding sites and underwent AE, with angiographic and clinical bleeding control in 93 (91%). The rate of successful hemostasis by AE was identical in blunt and penetrating trauma patients. There was no major morbidity after AE. No factors predicted patients with a high likelihood to have a positive angiogram. Patients who had AE before or after a period of attempted hemodynamic stabilization in the intensive care unit were no different with respect to hemodynamic parameters immediately before AE or effectiveness of AE for bleeding control. AE is a safe and effective method for controlling bleeding after blunt and penetrating intra- and retroperitoneal injuries. Early AE may be used in selected patients as a front-line therapeutic intervention that offers expeditious hemostasis and prevents delays in definitive bleeding control.

PENETRATING CARDIAC INJURIES

Penetrating cardiac injuries pose a tremendous challenge to any trauma surgeon. Time, sound judgment, aggressive intervention, and surgical technique are the most important factors contributing to positive outcomes. This article extensively reviews the history, surgical management, and techniques needed to deal with these critical injuries. This year commemorates the one hundredth anniversary of the first successful repair of a cardiac injury.

Initial evaluation and management of gunshot wounds to the face

BACKGROUND The literature on early management of gunshot wounds (GSWs) to the face is scant, with only six series reported in the English-language literature in the last 12 years. In the current study, we present a large series from a busy trauma center in an effort to identify early diagnostic and therapeutic problems and recommend management guidelines. METHODS Retrospective analysis was done for all GSWs of the face during a 4-year period. Data were obtained from the Trauma Registry and Trauma Patient Summary hard copies. RESULTS During the study period, there were 4,139 admissions for GSWs, with 247 (6%) involving the face. An associated brain trauma was found in 42 patients (17.0%), and cervical spine fracture was found in 20 patients (8.1%) with GSWs to the face. In 43 patients (17.4%), there was a need for emergency airway control because of local hematoma or edema. Angiography was performed in 70 patients (28.3%) for evaluation of a large hematoma or continuous bleeding, and in 10 of these patients successful embolization of bleeders was achieved. No patient required operative control of bleeding from facial structures. Overall, only 96 patients (38.9%) underwent operation for soft-tissue repair or reduction of facial bone fractures. There were 36 deaths (14.5%) from severe brain injury or severe bleeding from associated chest or abdominal injuries. No death occurred in isolated GSWs to the face. CONCLUSION Most civilian GSWs can safely be managed nonoperatively. Airway control is required in a significant number of patients and should be established very early. Bleeding from the face is best controlled angiographically. The brain and cervical spine should be aggressively assessed radiologically because of the high incidence of associated trauma.

Penetrating esophageal injuries: time interval of safety for preoperative evaluation--how long is safe?

OBJECTIVES This study was performed to assess the experience with penetrating esophageal injuries of an urban Level I trauma center and to attempt to correlate the time to establish a diagnosis with outcome including death, surgical intensive care unit length of stay, and esophageal-related complications. METHODS Retrospective study over a 72-month period at a single institution comparing age, admission blood pressure, Revised Trauma Score (RTS), Injury Severity Score (ISS), mechanism and anatomic location of injury, and time interval from admission to the operating room (OR) between nonsurvivors and survivors. Patients who survived to reach the operating room were divided into two groups: those who went immediately to the operating room (no preoperative evaluation) and those who underwent diagnostic studies to identify their injuries (preoperative evaluation). Data analysis was done of the same parameters plus average number of associated injuries, complications, and intensive care unit length of stay. Statistical methods used univariate analysis (Fishers exact test and Students t test). RESULTS Forty-three patients were identified with penetrating esophageal injuries and had the following characteristics: 36 males (84%) and 7 females (16%); mean RTS, 9.39; mean ISS, 28.1; mean time interval to OR, 9.8 hours. Associated injuries occurred with 42 patients (98%). The overall complication rate was 14 of 32 (44%), and the overall mortality was 11 of 43 (26%). Corrected mortality was 22%. Differences were noted between nonsurvivors and survivors in the following parameters: admission blood pressure < 90, 11 of 11 versus 3 of 29 (p < 0.001); RTS, 2.364 versus 11.406 (p < 0.001); ISS, 45 versus 21 (p < 0.001); time interval from admission to OR, 18.3 minutes versus 9.8 hours (p < 0.05). Thirty-six patients survived to reach the operating room, 18 in the no preoperative evaluation group and 17 in the preoperative evaluation group. No statistically significant differences were noted between these two groups in the following parameters: age, RTS, ISS, admission blood pressure, anatomic location of injury, number of associated injuries, or intensive care unit length of stay. Average length of time to the operating room was 16.7 hours in the preoperative evaluation group and 1.4 hours in the no preoperative evaluation group (p < 0.001). Twelve complications (all esophageal-related) occurred among seven patients in the preoperative evaluation group, and seven complications (five esophageal-related) occurred among seven patients in the no preoperative evaluation group. Because of the small sample size, this failed to reach a statistical difference (p < 0.05). CONCLUSIONS Esophageal injuries carry a high morbidity and mortality. Although no definite conclusion can be drawn because of the small sample size, there does appear to be an increased morbidity associated with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, the rapid diagnosis and definitive repair of esophageal injury should be made a high priority.

Operative Management of Civilian Rectal Gunshot Wounds: Simpler Is Better

Extraperitoneal rectal gunshot wounds have been managed with a variety of methods from simple diverting colostomy to combinations of rectal repair, proximal diversion, transperitoneal or presacral drainage, and distal bowel irrigation techniques. Treatment methodology is chosen based on anecdotal experience, and there is no clear evidence that any technique is superior to the others. The objective of this study was to compare 3 methods of managing civilian extraperitoneal gunshot wounds. Retrospective analysis of 30 consecutive patients with extraperitoneal rectal gunshot wounds was undertaken. Patients were treated with 1 of these 3 techniques: (1) simple diverting colostomy without rectal repair (group A, 12 patients); (2) diverting colostomy and rectal repair (group B, 12 patients); and (3) diverting colostomy and presacral drainage without repair (group C, 6 patients). Injury, hospital course, and outcome data were compared. The 3 groups were similar in age, injury severity, admission hemodynamics, preoperative and intraoperative time, blood loss, fecal contamination, and associated injuries. The overall incidence of complications was 27% (8/27): 25% (3/12) in group A, 33% (4/12) in group B, and 17% (1/6) in group C (p= NS). Complications directly associated with the rectal injury were found in 2 cases (7%): 1 group A patient developed a vesicorectal fistula and 1 group B patient developed a rectocutaneous fistula. For 10 patients with both rectal and bladder injuries, the complication rates for groups A, B, and C were 50%, 20%, and 0%, respectively (p= NS). No patient died. In conclusion, diverting colostomy without rectal repair or drainage appears to be safe for the management of most civilian retroperitoneal rectal gunshot wounds. Additional surgical maneuvers may be required for combined rectal and urinary trauma or other complex rectal injuries. Sound surgical principles, tailored to the individual case, should overrule any unproven dogmas.

A unified approach to the surgical exposure of pancreatic and duodenal injuries

One of the greatest challenges to any surgeon is the intraoperative detection and surgical management of duodenal and pancreatic injuries. A uniform approach to the surgical exposure of all suspected pancreatic and duodenal injuries will decrease their morbidity and mortality by identifying all injuries. Proper intraoperative assessment and grading will help with procedure selection from the broad surgical armamentarium available to manage these injuries.

Duration of antibiotic prophylaxis in high-risk patients with penetrating abdominal trauma: a prospective randomized trial.

To evaluate the effect of varying durations of antibiotic prophylaxis in trauma patients with multiple risk factors for postoperative septic complications, a prospective randomized trial was undertaken at an urban level I trauma center. The inclusion criteria were full-thickness colon injury and one of the following: (1) Penetrating Abdominal Trauma Index ≥25, (2) transfusion of 6 units or more of packed red blood cells, or (3) more than 4 hours from injury to operation. Patients were randomly assigned to a short course (24 hours) or a long course (5 days) of antibiotic therapy. All patients received 2 g cefoxitin en route to the operating room and 2 g intravenously piggyback every 6 hours for a total of 1 day vs. 5 days. Sixty-three patients were equally divided into short-course (n = 31) and long-course (n = 32) therapy. This was a high-risk patient population, as assessed by the mean Penetrating Abdominal Trauma Index (33), number of patients with multiple blood transfusions (51 of 63; 81%), number of patients with an Injury Severity Score greater than 15 (37 of 63; 59%), number of patients with destructive colon wounds requiring resection (27 of 63; 43%), and number of patients requiring postoperative critical care (37 of 63; 59%). Differences in intra-abdominal (1-day, 19%; 5-days, 38%) and extra-abdominal (1-day, 45%; 5-days, 25%) infection rates did not achieve statistical significance. There continues to be no evidence that extending antibiotic prophylaxis beyond 24 hours is of benefit, even among the highest risk patients with penetrating abdominal trauma. A large, multi-institutional trial will be necessary to condemn this common practice with statistical validity.